Interview: health fee for Americans on 'visitor' visas is ‘only fair’, says French politician behind plan

France's députés (MPs/congressmen) adopted an amendment to the 2026 social security finance law, calling for Americans and other non-EU nationals coming to France on long-stay 'visitor' visas to pay a new 'minimal fee' towards their healthcare. The draft bill containing this is now under examination in the Senate. We spoke to Francois Gernigon (Horizons, Maine-et-Loire, Pays de la Loire).

Liv Rowland: What gave you the idea? Did you have any specific examples in mind? For example, in putting forward your amendment you mentioned expatriate agencies that promote the idea of coming to take advantage of the free healthcare system. Did you see anything in particular?

François Gernigon: I have a constituent who is French and married to an American. They lived in the US for many years.

Now they have returned to France. They have American friends who live in France and who are indignant that they can benefit from our social security system without paying anything. So, she came to talk to me about it.

She showed me newspaper articles, including articles from CNN. And as we were approaching the budget debate, I said that I would table an amendment on the subject, to discuss the issue and then put it on the table. Personally, it was new to me.

I realised that no one was aware of the consequences of this law [creating the 'Puma' system of healthcare rights via residency], which dates from 2016. Even the authorities, I feel, are only now discovering the consequences of this issue. So what I am advocating is not at all about castigating our American friends.

In fact, we talk about Americans, but in reality, it's all foreign nationals outside the EU who benefit in some way from these conditions. That is to say, you have to reside in France for at least three months and have a long-stay visa. To do this, you have to prove your income, prove that you have private insurance, and then after three months, you can get a health insurance card without paying any contributions, just like that, for free.

And foreign nationals cancel their private insurance and benefit from health coverage in France. So, I'm not against it, but on condition that there is a contribution. And then, it's a question of fairness because French nationals, when they are abroad, do not benefit from the same conditions.

LR: There was a sub-amendment that was also voted on, which said that, in principle, there will be a decree that will examine whether there should be exceptions according to the social security agreements that exist with certain countries. Do you think that's normal?

FG: In any case, my amendment and the sub-amendment that was voted on are following their legislative path. That means that as of now, the text has gone to the Senate. We'll see how the Senate deals with the issue.

Once the text comes back from the Senate, I will take a look at how it has evolved. And I will, of course, remain attentive to the issue, to see what decree may be issued, or whether the law needs to be modified.

LR: It is possible, upon examination of the existing bilateral agreements, that there are some where there is a certain degree of reciprocity...

FG: Reciprocity does not mean fairness. In France, we have a health insurance system that is unique in the world, and is surely the best in the world.

That is why we are in financial difficulty. We must not hide from this fact. It is certain that contributions from foreign nationals will not fill the social security gap, but they will at least contribute to it.

It is a question of justice and, above all, a question of fairness. When we talk about international agreements, yes, but on condition that they are fair. And today, they are not fair, far from it.

LR: Yes, because I looked at which countries France has social security agreements with. There's the United States, for example, but I don't think that a French person who moves to the US benefits from free healthcare there.

FG: Yes, when we talk about reciprocal agreements, they must also be fair.

A French national who goes to live in the US will not have the same social security coverage as an American national who comes to live in France. Fairness must be restored.

LR: You may be aware that British nationals who are retired from the British social security system, because of the Brexit agreements, can benefit via the S1 form, like Europeans, which means that the UK pays for their healthcare costs. For example, I think they would be exempt.

FG: Yes, definitely. 

LR: We have spoken to several associations for Americans, and most seem to think it is reasonable for the people you are talking about to contribute, provided that the membership fee is set at a reasonable level. Do you have any idea what level, how much the minimum fee should be?

FG: No, not at all. I think it's a subject that has been put on the table for discussion.

LR: When you tabled the amendment, you did not mention the cotisation subsidiaire maladie, sometimes referred to as the Puma tax, which already exists. You have to have a fairly high level of capital income to pay this tax. I imagine you think it is insufficient?

FG: Let's say that it applies to certain nationals who have high incomes in France, yes, but that is not the majority of American nationals who benefit from social security coverage, not at all.

LR: In addition, retirement pensions are not part of the income assessed to work out this Puma tax because they are not considered to come from capital. One idea I have heard is that perhaps foreign pensions should be considered in working out this existing contribution? What do you think?

FG: The idea was to talk about the subject, to  bring it up, to say that there is a kind of injustice.

The French today are very sensitive to everything related to social justice, everything related to fairness, especially given the financial situation of our social security system. So it is a concern. The terms and conditions for financing the contribution remain to be determined.

This work remains to be done, and I am waiting to see the feedback on the draft social security finance bill from the Senate to get an idea of how the Senate has dealt with the issue and what remains to be done to reach a solution.

LR: What reactions have you had so far? Have you had any feedback from the people concerned or from Americans?

FG: I have had feedback from foreign nationals who thank me for talking about the subject.

Because for them, yes, they are indignant that they can benefit from this for free without paying anything.

LR: When they created this Puma - universal health protection - the idea was to simplify things a little by saying that people who were stable residents in France had a right to healthcare. Is there a risk that this will complicate the concept a little?

FG: It's this notion of residence which, in my opinion, has perhaps been misinterpreted or poorly thought out. Yes, it's perfectly normal for a French national who resides in France and has no income to be able to benefit from Puma. However, in the case of a foreign national, I think that conditions should be imposed, in the interests of fairness.

LR: The minister Amélie de Montchalin mentioned in the debate on the amendment the possibility of revising certain agreements. It was not clear if she was referring to social security agreements or double taxation agreements. Do you know what she was talking about? We cannot revise such agreements unilaterally.

FG: I think that, in terms of taxation, we shouldn't change anything. It's mainly in the area of social security coverage.

In terms of taxation, I think it's normal that our income is taxed in our countries of origin. It seems fair to me. Even if we live abroad. However, it's in the area of social security that there's an issue.